[纸质辅助数字任务数据记录的主要文档质量。空中救援服务的初步结果]

[Primary documentation quality for paper-assisted digital mission data documentation. Initial results from the air rescue service].

作者信息

Helm M, Hauke J, Schlechtriemen T, Renner D, Lampl L

机构信息

Abteilung für Anästhesiologie und Intensivmedizin-Sektion Notfallmedizin, Bundeswehrkrankenhaus Ulm, Oberer Eselsberg 40, 89070 Ulm, Deutschland.

出版信息

Anaesthesist. 2009 Jan;58(1):24-9. doi: 10.1007/s00101-008-1435-6.

Abstract

BACKGROUND

With the assistance of digital pen and paper technology in the field of prehospital data reporting, it seems to be possible to fulfill the requirements of "documentation" as well as the requirements of "quality management". The aim of this study was to determine the "primary documentation quality" (PDQ) of a data reporting system based on digital pen and paper technology (so-called DINO) within a helicopter emergency medical service (HEMS) over a 6-month period.

RESULTS

The PDQ is defined as the proportion of prehospital documented data, which is primarily recorded correctly by the data reporting system. For the national uniform core dataset (so-called MIND2) the PDQ was 96.7%, for "checkbox" and "numeric data fields" the PDQ was 99.8% and 93.6%, respectively and for "vital data" the PDQ was 96.7% [heart rate (HF), measurement of blood pressure] and 84.1% [peripheral oxygen saturation (S(p)O2), end tidal carbon dioxide concentration (etCO2), oxygen administration (O2)]. For "measurements" the PDQ was 96.9% (time stamps) and 86.9% (time frames), for "drugs" the PDQ was 43.6% (drug name) and 69.8% (drug dosage) and for"placement of infusion" 42% (infusion name) and 85.3% (infusion time), respectively. The average time for the "verification process" after mission completion was 1.5+/-0.4 min/mission.

CONCLUSIONS

The "primary documentation quality" of prehospital mission data reporting with the assistance of a digital pen and paper based documentation system (DINO) has been shown to completely fulfill the requirements of rapid and safe data documentation in actual missions, even at this early stage of development.

摘要

背景

借助院前数据报告领域的数字笔和纸技术,似乎有可能满足“文档记录”以及“质量管理”的要求。本研究的目的是确定基于数字笔和纸技术(所谓的DINO)的数据报告系统在直升机紧急医疗服务(HEMS)中6个月期间的“主要文档质量”(PDQ)。

结果

PDQ定义为院前记录数据的比例,该数据主要由数据报告系统正确记录。对于国家统一核心数据集(所谓的MIND2),PDQ为96.7%,对于“复选框”和“数字数据字段”,PDQ分别为99.8%和93.6%,对于“生命数据”,PDQ为96.7%[心率(HF)、血压测量]和84.1%[外周血氧饱和度(S(p)O2)、呼气末二氧化碳浓度(etCO2)、氧气供应(O2)]。对于“测量”,PDQ为96.9%(时间戳)和86.9%(时间范围),对于“药物”,PDQ为43.6%(药物名称)和69.8%(药物剂量),对于“输液放置”,分别为42%(输液名称)和85.3%(输液时间)。任务完成后“验证过程”的平均时间为1.5±0.4分钟/任务。

结论

即使在开发的早期阶段,借助基于数字笔和纸的文档系统(DINO)进行院前任务数据报告的“主要文档质量”已被证明完全满足实际任务中快速安全数据记录的要求。

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